Review Article
HPV Vaccination Syndrome: A Clinical Mirage, or a New Tragic Fibromyalgia Model
Síndrome posvacunal VPH. ¿Un espejismo clínico, o un nuevo modelo trágico de fibromialgia?
Manuel Martínez-Lavín
Departamento de Reumatología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
Read
18028
Timeswas read the article
2731
Total PDF
15297
Total HTML
Share statistics
array:24 [ "pii" => "S2173574318300741" "issn" => "21735743" "doi" => "10.1016/j.reumae.2018.01.001" "estado" => "S300" "fechaPublicacion" => "2018-07-01" "aid" => "1195" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología" "copyrightAnyo" => "2018" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Reumatol Clin. 2018;14:211-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "formatos" => array:2 [ "HTML" => 1 "PDF" => 1 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S1699258X18300354" "issn" => "1699258X" "doi" => "10.1016/j.reuma.2018.01.014" "estado" => "S300" "fechaPublicacion" => "2018-07-01" "aid" => "1195" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Reumatol Clin. 2018;14:211-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 7377 "formatos" => array:3 [ "EPUB" => 103 "HTML" => 6412 "PDF" => 862 ] ] "es" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Revisión</span>" "titulo" => "Síndrome posvacunal VPH. ¿Un espejismo clínico, o un nuevo modelo trágico de fibromialgia?" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "211" "paginaFinal" => "214" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "HPV vaccination syndrome: A clinical mirage, or a new tragic fibromyalgia model" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Manuel Martínez-Lavín" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Manuel" "apellidos" => "Martínez-Lavín" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173574318300741" "doi" => "10.1016/j.reumae.2018.01.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574318300741?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X18300354?idApp=UINPBA00004M" "url" => "/1699258X/0000001400000004/v2_201808030430/S1699258X18300354/v2_201808030430/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2173574318300753" "issn" => "21735743" "doi" => "10.1016/j.reumae.2018.07.001" "estado" => "S300" "fechaPublicacion" => "2018-07-01" "aid" => "1247" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Reumatol Clin. 2018;14:215-23" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "formatos" => array:2 [ "HTML" => 1 "PDF" => 1 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>" "titulo" => "The Patient Information Sheet (PIS) and Informed Consent (IC) for case reports and case series: Proposal for a standard model for presentations in congresses and other scientific publications" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "215" "paginaFinal" => "223" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hoja de información al paciente y consentimiento informado de casos clínicos y series de casos: propuesta de un modelo estandarizado para comunicaciones en congresos y otras publicaciones científicas" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juana Cruz del Río, Isabel Sastre Gervás, Susana Romero Yuste" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Juana" "apellidos" => "Cruz del Río" ] 1 => array:2 [ "nombre" => "Isabel" "apellidos" => "Sastre Gervás" ] 2 => array:2 [ "nombre" => "Susana" "apellidos" => "Romero Yuste" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X1830130X" "doi" => "10.1016/j.reuma.2018.07.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X1830130X?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574318300753?idApp=UINPBA00004M" "url" => "/21735743/0000001400000004/v1_201808070503/S2173574318300753/v1_201808070503/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S217357431830056X" "issn" => "21735743" "doi" => "10.1016/j.reumae.2017.01.009" "estado" => "S300" "fechaPublicacion" => "2018-07-01" "aid" => "1011" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Reumatol Clin. 2018;14:207-10" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "PDF" => 1 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Effect of Weight Loss on Activity in Psoriatic Arthritis: A Systematic Review" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "207" "paginaFinal" => "210" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Efecto de la pérdida de peso en la actividad en artritis psoriásica: una revisión sistemática" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1575 "Ancho" => 1645 "Tamanyo" => 161352 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flowchart documenting the search and selection of studies.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Raquel Almodóvar, Pedro Zarco, Teresa Otón, Loreto Carmona" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Raquel" "apellidos" => "Almodóvar" ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Zarco" ] 2 => array:2 [ "nombre" => "Teresa" "apellidos" => "Otón" ] 3 => array:2 [ "nombre" => "Loreto" "apellidos" => "Carmona" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X1730030X" "doi" => "10.1016/j.reuma.2017.01.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X1730030X?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357431830056X?idApp=UINPBA00004M" "url" => "/21735743/0000001400000004/v1_201808070503/S217357431830056X/v1_201808070503/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>" "titulo" => "HPV Vaccination Syndrome: A Clinical Mirage, or a New Tragic Fibromyalgia Model" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "211" "paginaFinal" => "214" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Manuel Martínez-Lavín" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Manuel" "apellidos" => "Martínez-Lavín" "email" => array:1 [ 0 => "drmartinezlavin@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Reumatología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome posvacunal VPH. ¿Un espejismo clínico, o un nuevo modelo trágico de fibromialgia?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Vaccination has been one of the most successful public health strategies in the history of medicine. Dreadful diseases like smallpox and poliomyelitis have practically been eradicated. This undeniable success has multiple programs of universal immunization. However, as in any effective biological therapy, an excessive dosage can provoke damage. This would appear to be the situation of vaccination against human papillomavirus (HPV).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The present review reports how having seen two cases of a serious syndrome that appeared to be like fibromyalgia that developed soon after HPV vaccination<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> led us to investigate the strength of the possible link between these two events. The study suggests that there is an actual relationship between vaccination against HPV and the development of chronic painful conditions.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> This article proposes that the controversial HPV vaccination syndrome could become a new tragic and undesirable model of fibromyalgia. On the other hand, recent research on the pathogenesis and treatment of fibromyalgia could provide diagnostic and therapeutic guidelines for those individuals affected by a chronic condition soon after immunization against HPV.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Background</span><p id="par0015" class="elsevierStylePara elsevierViewall">Our group has been dedicated to investigate the mechanisms that lead to fibromyalgia. We propose that dysautonomia is the common underlying pathogenesis of fibromyalgia and other related syndromes, such as complex regional pain syndrome and chronic fatigue.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a> We also suggest that fibromyalgic pain is of neuropathic origin<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> and, moreover, that the sodium channels located in the dorsal root ganglia may have an important role as sympathetic-nociceptive short-circuit sites.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> This proposal has recently been supported by the finding of small fiber neuropathy in a considerable percentage of individuals with fibromyalgia<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> and complex regional pain syndrome.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The First Cases of Adverse Events Following Human Papillomavirus Vaccination: An Anecdote in the Setting of Evidence-based Scientific Medicine</span><p id="par0020" class="elsevierStylePara elsevierViewall">In 2014, we published the findings in two girls who developed a serious condition that was similar to fibromyalgia soon after receiving the HPV vaccine.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> In evidence-based scientific medicine, case reports are located in the lowest level of the hierarchy of evidence. However, the issuing of case reports is also considered an early and important warning in the process of drug surveillance.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">After the publication of those cases, we received messages from a number of countries in which physician, but especially the mothers of patients, wrote about similar incidents. Prior to this, the association between vaccination against HPV and another type of dysautonomia—postural orthostatic tachycardia syndrome—had also been reported.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> A short time later, two case series similar to ours were published by authors from Denmark<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> and Japan.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> The symptoms reported were very similar, but the diagnoses differed. The Japanese patients were mostly considered to have complex regional pain syndrome, whereas the Danish patients were often diagnosed with postural orthostatic tachycardia syndrome or chronic fatigue syndrome. The clinical manifestations of those affected included repetitively headache, myalgia, arthralgia, fatigue, dizziness, nausea and, less frequently, myoclonic disorders.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">10,11</span></a> On the basis of our research on fibromyalgia, we speculated that dysautonomia and small fiber neuropathy could be the hypothetical pathogeneses underlying HPV vaccination syndrome.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This type of reaction to vaccination against HPV appears to be rare. With our current knowledge it is not possible to calculate the incidence. However, there is general information about reports of adverse events in HPV vaccination. In a study performed in the Spanish Valencian Community between 2007 and 2011, the rate of reports of adverse effects was approximately 1 of 1000 doses of HPV vaccine administered. The reports were made by qualified healthcare professionals (physicians or nurses). Approximately a third of these undesirable events were classified as “serious”. This rate of notification was 10 times higher than that reported for other vaccines administered during the same period to girls of similar ages.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Subsequently, we asked individuals who had had a chronic disease after vaccination against HPV to complete three validated questionnaires: the 2010 American College of Rheumatology (ACR-2010), which enabled the diagnosis of fibromyalgia and established its severity; the Composite Autonomic Symptom Score (COMPASS-31), which detects symptoms of dysautonomia; and the Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), which measures the neuropathic component of chronic pain. Over a period of one month, we received 45 completed questionnaires from 13 different countries. In all, 29% of those surveyed detected the onset of their condition within 24<span class="elsevierStyleHsp" style=""></span>h after HPV vaccination. The most frequent presenting symptoms were headache, musculoskeletal pain, fatigue, dizziness/vertigo and paresthesias/allodynia. Overall, 53% of those surveyed met the diagnostic criteria of fibromyalgia. The high COMPASS-31 and S-LANSS scores indicated the presence of severe dysautonomia and severe neuropathic pain. After an average of 4.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.5 years, 92% of those affected remained disabled.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> In those patients who met the criteria for fibromyalgia, there was a correlation between the severity of the fibromyalgia measured by ACR-2010 and the intensity of dysautonomia scored by COMPASS-31.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The reaction of international health authorities to these independent publications was firm and adverse. The European Medicines Agency judged that there was no relationship between the vaccine against HPV and the development of complex regional pain syndrome or postural orthostatic tachycardia.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a> Reviews conducted by British,<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> Canadian<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> and Spanish<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> health authorities supported the safety of immunization against HPV. A powerful argument put forward by the defenders of this vaccine was that the large, double-blind, randomized preclinical studies guaranteed the safety of the HPV vaccine. These randomized studies have a higher level of reliability in evidence-based scientific medicine. Randomized studies eliminate the contrivances that have nothing in common with the intervention and the results are totally independent of the judgment of the researchers. Our next step was to analyze in detail the randomized preclinical studies and the case series that reported adverse incidents involving vaccination against HPV.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">An In-depth Analysis of the Randomized Studies Involving the Human Papillomavirus Vaccine Discovers Disturbing Data Regarding Its Safety</span><p id="par0045" class="elsevierStylePara elsevierViewall">A critical analysis of the safety profile of the vaccine against HPV<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> reveals the following data:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0050" class="elsevierStylePara elsevierViewall">The great majority of the randomized trials with the HPV vaccine did not utilize as control a true placebo, but an aluminum adjuvant. In clinical trials, the placebo is defined as an inert substance. Obviously, the aluminum adjuvant does not have this property. The innocuousness of the aluminum adjuvant has been put into question.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> Strictly speaking, these controlled trials do not compare the efficacy or the safety of the HPV vaccine. They compare only the part of the vaccine that contains particles similar to HPV.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Two of the large preclinical randomized trials demonstrated more serious adverse incidents after vaccination against HPV. The VIVIANE study compared 2881 women injected with the bivalent HPV vaccine versus 2871 injected with the aluminum “placebo”. Over the 4-year follow-up period, there were 14 deaths in the immunized group versus 3 deaths in the control group. The difference is statistically significant. Fisher's exact test produced a <span class="elsevierStyleItalic">P</span>-value of .01. The researchers who conducted this randomized trial deemed that none of the deaths were attributable to the injections administrated.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a></p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">The largest double-blind study involving Gardasil compared the efficacy and safety of the new Gardasil-9 versus the tetravalent Gardasil employed at the present time. Gardasil-9 contains more than twice the HPV virus-like particles and more than twice the aluminum adjuvant than its predecessor. Serious adverse incidents were more frequent with Gardasil-9 (3.3%) than with the tetravalent formula (2.6%). We calculate a <span class="elsevierStyleItalic">P</span>-value of .012. The researchers considered that 0% of the adverse events in the two arms of the study were due to the intervention.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The results of the statistical analyses of these two pivotal studies are distressing. There are more serious adverse effects in the patients who received the HPV vaccine being investigated. Nevertheless, these findings were avoided by the authors, who turned to stressing the fact that the researchers in both cases deemed that 0% of the adverse incidents were related to the intervention. In these two fundamental studies of vaccination against HPV, the solid and disturbing statistical results were ignored and subordinated to the opinion of the investigators.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Independent Researchers Report Similar Symptoms After Vaccination Against Human Papillomavirus</span><p id="par0070" class="elsevierStylePara elsevierViewall">Other data that support the veracity of HPV vaccination syndrome lie in the fact that independent reports from different parts of the world describe a similar group of post-vaccine symptoms that include headache, fatigue, myalgias, paresthesias and dizziness, among others.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">9–11,13</span></a> This composite of adverse symptoms had been mentioned in randomized preclinical trials. The difficulty arises upon attempting to label this pleiad of symptoms with a precise diagnosis. The study of the database of adverse effects of the World Health Organization (VigiBase) highlights this problem. Cases of headache, dizziness, fatigue and syncope were reported more frequently and were more severe after vaccination against HPV when compared with other types of immunizations administered to individuals of a similar age. However, a minority of the reports mentioned a specific diagnosis.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a> The lack of an explicit diagnosis and the dilution of the vaccine employed in cases of the HPV vaccination syndrome in different diagnoses is a possible explanation for the failure to recognize the adverse effects of this vaccine on the part of drug regulatory agencies.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In many cases, the syndrome reported as an adverse effect of immunization against HPV meets the diagnostic criteria of fibromyalgia. This was the situation of approximately half of the patients with whom we contacted.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Human Papillomavirus Vaccination Syndrome: A Model of Fibromyalgia?</span><p id="par0080" class="elsevierStylePara elsevierViewall">Human papillomavirus vaccination syndrome described independently by a number of researchers could become a model that would aid in the understanding of the pathogenesis of fibromyalgia. This disabling disease generally presents in healthy young individuals. It could be that, in some cases, vaccination against HPV acts as a trigger for fibromyalgia or chronic fatigue in predisposed persons or with a history of previous disorders. A study conducted in Denmark demonstrated that the patients who developed symptoms after HPV vaccination had a significantly higher rate of pre-vaccination care-seeking than those who did not.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In cases of HPV vaccination syndrome, the date of onset of the condition and that of administration of the trigger are well identified. The most widespread symptoms are typical of fibromyalgia: headache, generalized pain, paresthesias and fatigue. It must be stressed that some of these individuals have also mentioned movement disorders such as tremors and myoclonus. These motor disorders are a well-recognized complication of complex regional pain syndrome. Those affected by HPV vaccination syndrome have severe dysautonomia.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> In these cases, there is a correlation between the severity of fibromyalgia and the severity of dysautonomia.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> Individuals who develop a chronic condition after vaccination against HPV have antibodies against key elements of the autonomic nervous system, such as antibodies against adrenergic and muscarinic receptors.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">23,24</span></a> In the few patients in whom this has been investigated, physicians encountered small fiber neuropathy.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">9,11,24</span></a> Should this be verified, this new tragic model would support the dysautonomic and neuropathic pathogenesis of fibromyalgia.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Advances in the Understanding of the Pathogenesis of Fibromyalgia Could Provide Diagnostic Strategies for Patients With Adverse Effects to Vaccination Against Human Papillomavirus</span><p id="par0090" class="elsevierStylePara elsevierViewall">The dysautonomic–neuropathic model of fibromyalgia could provide diagnostic guidelines for those individuals who develop a chronic condition after HPV vaccination. A major problem in these cases has been the absence of a proper diagnosis. The application of the COMPASS-31, S-LANSS and ACR-2010 questionnaires would help to identify the existence of dysautonomia, neuropathic pain and fibromyalgia, respectively. The tilt-table test would recognize postural orthostatic tachycardia or other syndromes involving orthostatic intolerance. Skin biopsy would identify the presence of small fiber neuropathy. The search for antibodies to adrenergic and muscarinic receptors could become a useful tool in the diagnostic process of HPV vaccination syndrome.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">New Pathogenetic Knowledge on Fibromyalgia Could Provide Therapeutic Indications for Human Papillomavirus Vaccination Syndrome</span><p id="par0095" class="elsevierStylePara elsevierViewall">At the present time, drug treatment for fibromyalgia leaves much to be desired. However, based on new pathophysiological knowledge, there is investigation underway involving selective blockers of sodium channels located in the dorsal root ganglia<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a> These substances could become an effective analgesic for HPV vaccination syndrome. The infusion of immunoglobulins or plasmapheresis could be useful in those cases of HPV vaccination syndrome in which there are antibodies against adrenergic or muscarinic receptors.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">23,24</span></a> Pyridostigmine, fludrocortisone and propranolol utilized in orthostatic intolerance syndromes<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> could be extrapolated to the therapeutic armamentarium for HPV vaccination syndrome.</p><p id="par0100" class="elsevierStylePara elsevierViewall">It is evident that these diagnostic and therapeutic considerations are hypothetical and need to be subjected to the judgment of investigation.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0105" class="elsevierStylePara elsevierViewall">Independent investigators have reported the development of a fibromyalgia-like chronic syndrome after HPV vaccination. It is difficult to categorize the condition within a specific diagnosis. Recent advances in our understanding of fibromyalgia could provide diagnostic and therapeutic guidelines for the hypothetical HPV vaccination syndrome. On the other hand, should the veracity of HPV vaccination syndrome be corroborated, it could become a new tragic and undesired model of fibromyalgia. International health authorities deny the existence of such a syndrome. More research will be necessary to define HPV vaccination syndrome as a clinical mirage or as a new clinical entity.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The author declares he has no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1069482" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1016769" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1069483" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1016768" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Background" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "The First Cases of Adverse Events Following Human Papillomavirus Vaccination: An Anecdote in the Setting of Evidence-based Scientific Medicine" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "An In-depth Analysis of the Randomized Studies Involving the Human Papillomavirus Vaccine Discovers Disturbing Data Regarding Its Safety" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Independent Researchers Report Similar Symptoms After Vaccination Against Human Papillomavirus" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Human Papillomavirus Vaccination Syndrome: A Model of Fibromyalgia?" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Advances in the Understanding of the Pathogenesis of Fibromyalgia Could Provide Diagnostic Strategies for Patients With Adverse Effects to Vaccination Against Human Papillomavirus" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "New Pathogenetic Knowledge on Fibromyalgia Could Provide Therapeutic Indications for Human Papillomavirus Vaccination Syndrome" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-11-15" "fechaAceptado" => "2018-01-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1016769" "palabras" => array:6 [ 0 => "HPV vaccine" 1 => "Fibromyalgia" 2 => "Small fiber neuropathy" 3 => "Dysautonomia" 4 => "Chronic fatigue syndrome" 5 => "HPV vaccination syndrome" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1016768" "palabras" => array:6 [ 0 => "Vacuna del papiloma" 1 => "Fibromialgia" 2 => "Neuropatía de fibras pequeñas" 3 => "Disautonomía" 4 => "Síndrome de fatiga crónica" 5 => "Síndrome posvacunal de VPH" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Independent investigators have described the onset of a chronic painful dysautonomic syndrome soon after human papillomavirus (HPV) vaccination. The veracity of this syndrome is hotly debated. Many of the reported post-HPV vaccination cases fulfil fibromyalgia diagnostic criteria.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This article discusses the arguments favoring the existence of a syndrome associated to HPV vaccination. We propose that fibromyalgia dysautonomic-neuropathic model could help in the diagnostic and therapeutic process in those patients in whom the onset of a painful chronic illness began after HPV immunization. On the other hand, if its veracity is corroborated, HPV vaccination syndrome may become a new tragic fibromyalgia model.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Investigadores independientes han descrito la emergencia de un síndrome doloroso-disautonómico crónico enseguida de la vacunación contra el virus del papiloma humano (VPH). La veracidad de este síndrome es objeto de un encendido debate. Muchos de los casos reportados cumplen los criterios diagnósticos de fibromialgia.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Este artículo discute los argumentos a favor de la existencia de este nuevo síndrome. Propone que el modelo neuropático-disautonómico de la fibromialgia podría ayudar en el proceso diagnóstico y terapéutico de los casos que presentan un padecimiento doloroso crónico después de haber sido inmunizados frente al VPH. Por otro lado, de corroborarse su veracidad, el síndrome posvacunal VPH se erigiría como un nuevo modelo trágico e indeseado de fibromialgia.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martínez-Lavín M. Síndrome posvacunal VPH. ¿Un espejismo clínico, o un nuevo modelo trágico de fibromialgia? Reumatol Clín. 2018;14:211–214.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0130" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fibromyalgia-like illness in 2 girls after human papillomavirus vaccination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Martínez-Lavin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/RHU.0000000000000165" "Revista" => array:6 [ "tituloSerie" => "J Clin Rheumatol" "fecha" => "2014" "volumen" => "20" "paginaInicial" => "392" "paginaFinal" => "393" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25275771" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0135" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Serious adverse events after HPV vaccination: a critical review of randomized trials and post-marketing case series" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Martínez-Lavín" 1 => "L. Amezcua-Guerra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10067-017-3768-5" "Revista" => array:6 [ "tituloSerie" => "Clin Rheumatol" "fecha" => "2017" "volumen" => "36" "paginaInicial" => "2169" "paginaFinal" => "2217" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28730271" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0140" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sympathetic nervous system dysfunction in fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome and interstitial cystitis. A review of case-control studies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Martínez-Martínez" 1 => "T. Mora" 2 => "A. Vargas" 3 => "M. Fuentes-Iniestra" 4 => "M. Martínez-Lavín" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/RHU.0000000000000089" "Revista" => array:6 [ "tituloSerie" => "J Clin Rheumatol" "fecha" => "2014" "volumen" => "20" "paginaInicial" => "146" "paginaFinal" => "150" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24662556" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0145" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The use of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) questionnaire in fibromyalgia patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Martínez-Lavín" 1 => "S. López" 2 => "M. Medina" 3 => "A. Nava" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/sarh.2003.50017" "Revista" => array:6 [ "tituloSerie" => "Semin Arthritis Rheum" "fecha" => "2003" "volumen" => "32" "paginaInicial" => "407" "paginaFinal" => "411" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12833249" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0150" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A SCN9A gene-encoded dorsal root ganglia sodium channel polymorphism associated with severe fibromyalgia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Vargas-Alarcon" 1 => "E. Alvarez-Leon" 2 => "J.M. Fragoso" 3 => "A. Vargas" 4 => "A. Martinez" 5 => "M. Vallejo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "BMC Musculoskeletal Dis" "fecha" => "2012" "volumen" => "13" "paginaInicial" => "23" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0155" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Small fiber neuropathy in women with fibromyalgia: An in vivo assessment using corneal confocal bio-microscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Ramírez" 1 => "L.A. Martínez-Martínez" 2 => "E. Hernández-Quintela" 3 => "J. Velazco-Casapía" 4 => "A. Vargas" 5 => "M. Martínez-Lavín" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.semarthrit.2015.03.003" "Revista" => array:6 [ "tituloSerie" => "Semin Arthritis Rheum" "fecha" => "2015" "volumen" => "45" "paginaInicial" => "214" "paginaFinal" => "219" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26094164" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0160" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evidence of focal small-fiber axonal degeneration in complex regional pain syndrome-I (reflex sympathetic dystrophy)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.L. Oaklander" 1 => "J.G. Rissmiller" 2 => "L.B. Gelman" 3 => "L. Zheng" 4 => "Y. Chang" 5 => "R. Gott" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.pain.2005.09.036" "Revista" => array:6 [ "tituloSerie" => "Pain" "fecha" => "2006" "volumen" => "120" "paginaInicial" => "235" "paginaFinal" => "243" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16427737" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0165" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "In defense of case reports and case series" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.P. Vandenbroucke" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "2001" "volumen" => "134" "paginaInicial" => "330" "paginaFinal" => "334" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11182844" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0170" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postural tachycardia syndrome following human papillomavirus vaccination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S. Blitshteyn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ene.12272" "Revista" => array:6 [ "tituloSerie" => "Eur J Neurol" "fecha" => "2014" "volumen" => "21" "paginaInicial" => "135" "paginaFinal" => "139" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24102827" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0175" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Suspected side effects to the quadrivalent human papilloma vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L. Brinth" 1 => "A.C. Theibel" 2 => "K. Pors" 3 => "J. Mehlsen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Dan Med J" "fecha" => "2015" "volumen" => "62" "numero" => "A5064." ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0180" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Peripheral sympathetic nerve dysfunction in adolescent Japanese girls following immunization with the human papillomavirus vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T. Kinoshita" 1 => "R.T. Abe" 2 => "A. Hineno" 3 => "K. Tsunekawa" 4 => "S. Nakane" 5 => "S. Ikeda" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intern Med" "fecha" => "2014" "volumen" => "53" "paginaInicial" => "2185" "paginaFinal" => "2200" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25274229" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0185" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Human papillomavirus vaccination syndrome Small fiber neuropathy and dysautonomia could be its underlying pathogenesis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Martínez-Lavín" 1 => "Hypothesis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10067-015-2969-z" "Revista" => array:6 [ "tituloSerie" => "Clin Rheumatol" "fecha" => "2015" "volumen" => "34" "paginaInicial" => "1165" "paginaFinal" => "1169" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25990003" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0190" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse reactions to human papillomavirus vaccine in the Valencian Community (2007-2011)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.A. Rodríguez-Galán" 1 => "S. Pérez-Vilar" 2 => "J. Díez-Domingo" 3 => "J. Tuells" 4 => "J. Gomar-Fayos" 5 => "F. Morales-Olivas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "An Pediatr (Barc)" "fecha" => "2014" "volumen" => "81" "paginaInicial" => "303" "paginaFinal" => "309" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0195" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "HPV vaccination syndrome. A questionnaire-based study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Martínez-Lavín" 1 => "L.A. Martínez-Martínez" 2 => "P. Reyes-Loyola" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10067-015-3070-3" "Revista" => array:6 [ "tituloSerie" => "Clin Rheumatol" "fecha" => "2015" "volumen" => "34" "paginaInicial" => "1981" "paginaFinal" => "1983" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26354426" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0200" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Martínez-Lavín M, Reyes-Loyola PK, Martinez-Martinez LA. Human Papilloma virus vaccination, fibromyalgia and dysautonomia. Arthritis Rheumatol. 2016; 68 (suppl 10) [accessed 26 oct 2017]. Available from: <a id="intr0010" class="elsevierStyleInterRef" href="http://acrabstracts.org/abstract/human-papilloma-virus-vaccination-fibromyalgia-and-dysautonomia/">http://acrabstracts.org/abstract/human-papilloma-virus-vaccination-fibromyalgia-and-dysautonomia/</a>" ] ] ] 15 => array:3 [ "identificador" => "bib0205" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "HPV vaccines: EMA confirms evidence does not support that they cause CRPS or POTS. [accessed 5 mar 2017]. Available from: <a id="intr0015" class="elsevierStyleInterRef" href="http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/HPV_vaccines_20/European_Commission_final_decision/WC500196773.pdf">http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/HPV_vaccines_20/European_Commission_final_decision/WC500196773.pdf</a>" ] ] ] 16 => array:3 [ "identificador" => "bib0210" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bivalent human papillomavirus vaccine and the risk of fatigue syndromes in girls in the UK" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Donegan" 1 => "R. Beau-Lejdstrom" 2 => "B. King" 3 => "S. Seabroke" 4 => "A. Thomson" 5 => "P. Bryan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Vaccine" "fecha" => "2013" "volumen" => "31" "paginaInicial" => "7" "paginaFinal" => "4961" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0215" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse events following HPV vaccination Alberta 2006-2014" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "X.C. Liu" 1 => "C.A. Bell" 2 => "K.A. Simmonds" 3 => "L.W. Svenson" 4 => "M.L. Russell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.vaccine.2016.02.040" "Revista" => array:7 [ "tituloSerie" => "Vaccine" "fecha" => "2016" "volumen" => "34" "paginaInicial" => "1800" "paginaFinal" => "1805" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26921782" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0378512212003489" "estado" => "S300" "issn" => "03785122" ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0220" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy, safety, and immunogenicity of the human papillomavirus 16/18 AS04-adjuvanted vaccine in women older than 25 years: 4-year interim follow-up of the phase 3, double-blind, randomised controlled VIVIANE study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.R. Skinner" 1 => "A. Szarewski" 2 => "B. Romanowski" 3 => "S.M. Garland" 4 => "E. Lazcano-Ponce" 5 => "J. Salmerón" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Lancet" "fecha" => "2014" "volumen" => "84" "paginaInicial" => "2213" "paginaFinal" => "2227" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0225" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.A. Joura" 1 => "A.R. Giuliano" 2 => "O.E. Iversen" 3 => "C. Bouchard" 4 => "C. Mao" 5 => "J. Mehlsen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1405044" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2015" "volumen" => "372" "paginaInicial" => "711" "paginaFinal" => "723" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25693011" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0230" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current safety concerns with human papillomavirus vaccine: A cluster analysis of reports in VigiBase" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.E. Chandler" 1 => "K. Juhlin" 2 => "J. Fransson" 3 => "O. Caster" 4 => "I.R. Edwards" 5 => "G.N. Norén" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s40264-016-0456-3" "Revista" => array:6 [ "tituloSerie" => "Drug Saf" "fecha" => "2017" "volumen" => "40" "paginaInicial" => "81" "paginaFinal" => "90" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27638661" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0235" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pre-vaccination care-seeking in females reporting severe adverse reactions to HPV vaccine. A registry based case-control study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Molbak" 1 => "N.D. Hansen" 2 => "P. Valentiner-Branth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0162520" "Revista" => array:5 [ "tituloSerie" => "PLOS One" "fecha" => "2016" "volumen" => "11" "paginaInicial" => "e0162520" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27611088" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0240" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Human papilloma virus vaccination and dysautonomia: Considerations for autoantibody evaluation and HLA typing" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.E. Hendrickson" 1 => "C.A. Tormey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.vaccine.2016.05.029" "Revista" => array:5 [ "tituloSerie" => "Vaccine" "fecha" => "2016" "volumen" => "34" "paginaInicial" => "4468" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27553747" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0245" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Epub ahead of print]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autoimmunity autonomic neuropathy, and the HPV vaccination: a vulnerable subpopulation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.R. Schofield" 1 => "J.E. Hendrickson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0009922817728701" "Revista" => array:2 [ "tituloSerie" => "Clin Pediatr (Phila)" "fecha" => "2017" ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0250" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ambroxol for fibromyalgia: one group pretest-postest open-label pilot study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.A. Martínez-Martínez" 1 => "L.F. Pérez" 2 => "L.T. Becerril-Mendoza" 3 => "P. Rodríguez-Henriquez" 4 => "O.E. Muñoz" 5 => "G. Acosta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10067-017-3664-z" "Revista" => array:6 [ "tituloSerie" => "Clin Rheumatol" "fecha" => "2017" "volumen" => "36" "paginaInicial" => "1879" "paginaFinal" => "1884" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28466418" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001400000004/v1_201808070503/S2173574318300741/v1_201808070503/en/main.assets" "Apartado" => array:4 [ "identificador" => "8383" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Review Article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001400000004/v1_201808070503/S2173574318300741/v1_201808070503/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574318300741?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 2 | 8 |
| 2024 October | 261 | 47 | 308 |
| 2024 September | 303 | 36 | 339 |
| 2024 August | 280 | 51 | 331 |
| 2024 July | 287 | 30 | 317 |
| 2024 June | 253 | 39 | 292 |
| 2024 May | 216 | 51 | 267 |
| 2024 April | 210 | 63 | 273 |
| 2024 March | 191 | 41 | 232 |
| 2024 February | 182 | 51 | 233 |
| 2024 January | 278 | 37 | 315 |
| 2023 December | 222 | 31 | 253 |
| 2023 November | 326 | 32 | 358 |
| 2023 October | 376 | 31 | 407 |
| 2023 September | 589 | 45 | 634 |
| 2023 August | 388 | 23 | 411 |
| 2023 July | 293 | 41 | 334 |
| 2023 June | 217 | 45 | 262 |
| 2023 May | 389 | 33 | 422 |
| 2023 April | 174 | 26 | 200 |
| 2023 March | 191 | 45 | 236 |
| 2023 February | 175 | 40 | 215 |
| 2023 January | 148 | 33 | 181 |
| 2022 December | 168 | 49 | 217 |
| 2022 November | 159 | 41 | 200 |
| 2022 October | 264 | 49 | 313 |
| 2022 September | 224 | 95 | 319 |
| 2022 August | 169 | 56 | 225 |
| 2022 July | 143 | 66 | 209 |
| 2022 June | 211 | 42 | 253 |
| 2022 May | 166 | 44 | 210 |
| 2022 April | 192 | 71 | 263 |
| 2022 March | 291 | 67 | 358 |
| 2022 February | 267 | 56 | 323 |
| 2022 January | 317 | 86 | 403 |
| 2021 December | 235 | 60 | 295 |
| 2021 November | 254 | 70 | 324 |
| 2021 October | 341 | 69 | 410 |
| 2021 September | 762 | 69 | 831 |
| 2021 August | 339 | 72 | 411 |
| 2021 July | 348 | 39 | 387 |
| 2021 June | 229 | 52 | 281 |
| 2021 May | 408 | 65 | 473 |
| 2021 April | 920 | 161 | 1081 |
| 2021 March | 617 | 73 | 690 |
| 2021 February | 372 | 40 | 412 |
| 2021 January | 343 | 37 | 380 |
| 2020 December | 379 | 70 | 449 |
| 2020 November | 439 | 21 | 460 |
| 2020 October | 113 | 24 | 137 |
| 2020 September | 158 | 60 | 218 |
| 2020 August | 237 | 24 | 261 |
| 2020 July | 95 | 34 | 129 |
| 2020 June | 65 | 32 | 97 |
| 2020 May | 57 | 31 | 88 |
| 2020 April | 42 | 23 | 65 |
| 2020 March | 17 | 9 | 26 |
| 2020 February | 1 | 0 | 1 |
| 2018 December | 0 | 1 | 1 |
Show all
